homicide by heart attack

A frequent forensic difficulty arises in circumstances where an individual dies following an altercation, and is found at post mortem examination to have significant ischaemic heart disease, for example.

When dealing with a case where there is pathological evidence of significant natural disease, such that without knowing the surrounding circumstances, there is a satisfactory explanation for death, how can the role of any altercation be assessed?

A verbal altercation has physiological consequences even without physical contact, and thus provide a ‘trigger’ for sudden cardiac death, in the predisposed individual. The implications of death in such circumstances are different to those involving a physical assault, as it is not necessarily illegal to argue with someone (‘threats’ may be illegal).

‘Common sense’ might think it too much of a coincidence that a man drops dead on the spot following an altercation, however severe his disease. The strict legal test is 'would he not have died when he did die had the physical assault not taken place?’

The fact that a person is in a poor state of health and might die from minimum trauma is no defence – ‘an assailant must take his victims as he finds them’ although the defence could reasonably claim that death could have occurred at any time (Knight and Saukko 2004).

The legal ‘standard of proof’ for a criminal case is proof beyond all reasonable doubt, which means proof to a high degree of probability but not proof beyond a shadow of a doubt (Miller v Minister of Pensions (1947)).

The prevalence of coronary artery disease, for example, is so high and the frequency of physical 'triggers' in everyday life so great that a temporal association between a ‘trigger’ and ‘collapse’ is insufficient to determine causal effect.

It may be impossible to prove such a causal link to the highest standard of proof. Where delay between the ‘trigger’ and ‘collapse’ occurs there is inevitably further doubt about the nature of any causal link, particularly where other potential triggers have time to act.

Davis (1978) set out criteria by which American Medical Examiners might determine the manner of a cardiac death as ‘homicide’;

The criminal act should be of such severity and have such sufficient elements of intent to kill or maim, either in fact or in statute, so as to lead logically to a charge of homicide in the event that physical injury had ensued.

The victim should have realised that the threat to personal safety was implicit. A logical corollary would be a feared threatening act against a loved one or friend.

The circumstances should be of such a nature as to be commonly accepted as highly emotional.

The collapse and death must occur during the emotional response period, even if the criminal act had already ceased.

The demonstration of an organic cardiac disease process of a type commonly associated with a predisposition to lethal cardiac arrhythmia is desirable.

These criteria were further modified in 2004 (Turner et al) to take into account cases where injury has occurred (unlike Davis) and incorporates National Association of Medical Examiners (NAME) guidelines (‘Guide for Manner of Death Classification’).

‘Deaths resulting from fear or fright that is caused by verbal assault, threats of physical harm, or via acts of aggression intended to instil fear may be classified as homicide, as long as there is a close temporal relationship between the incident and the death’.

The action of the perpetrator towards the victim should be of such severity and have sufficient elements of intent to frighten, injure or kill, either in fact or in statute, so as to lead logically to a charge of homicide in the event that the death resulted from physical injury.

The victim should have realised that the threat to personal safety was implicit. A logical corollary would be a feared threatening act against a loved one or friend.

The circumstances should be of such a nature as to be commonly accepted as highly emotional.

The collapse (and subsequent death, in most cases) must occur within the emotional response period, even if the criminal act had already ceased. In certain circumstances, death may be delayed, typically via medical intervention.

Autopsy should demonstrate an organic cardiac disease process of a type commonly associated with a predisposition to lethal cardiac arrhythmia. In the absence of a grossly or microscopically identifiable organic cardiac disease, the case may involve a functional cardiac disorder (such as a conduction system disorder) that has no anatomic correlation.

Recovery after initial collapse, then death following decompensation would not be properly regarded as homicide in the view of some authors (Turner et al 2004)